Syria ER: Performing Amputations with Little Electricity

Syrian-American Samer Attar is an orthopedic surgeon on staff at Northwestern Memorial Hospital and the Ann & Robert H. Lurie Children's Hospital of Chicago. In August, he spent two weeks working at a field hospital in Aleppo on a trip facilitated by the Syrian American Medical Society. "I fix broken bones, and I also specialize in reconstruction," he says. "I do a lot of trauma work and I do a lot of amputations. In Syria, I found myself doing a lot more of them. Doing an amputation there is a lot like doing it in the rest of the world, but with fewer resources."

We were close to the front lines in Aleppo. I did treat some fighters here and there but most were civilians, men, women and children going from place to place trying to get food. A lot of the injuries were from sniper bullets, shrapnel flying through the air, rubble collapsing on arms or legs, or people hit by air strikes. A whole family came in with burns because their home propane tank got hit.

They had things available to use for amputations; you don't need much. You need a scalpel to make incisions, you need surgical ties, you need to know anatomy. It was never a question of surgical skill, it was a question of resources. A lot of the time you're cutting through bone in an operating room in the U.S., you're doing it with an electrical saw. In Syria, saws were very dull and electricity was never a sure thing, so it was harder and it took a lot longer.

You had to work rather efficiently to keep blood loss to a minimum. Doing amputations was the hardest part for the surgeons. And it was hard emotionally. A lot of civilians had survived their shrapnel wounds and now had external devices stabilizing their wounds. Without access to appropriate wound care, or plastic surgery for soft tissue coverage, a lot of them would get infected.

There were people who requested amputations because they couldn't live any more with a leg with exposed bone and pus just pouring out of the wound. A number of the amputations were on children: the surgeons there showed me pictures of a lot of the kids they had operated on.

We had anesthesia in the operating room, but there are only so many operating rooms [in these hospitals] and you can't take everyone there. So sometimes in the emergency department, some had to be done without anesthesia, maybe using a local anesthetic, like when you're doing sutures and pulling out shrapnel. And there are reports of using kitchen tables to perform surgery, because hospitals have been destroyed and places like schools and farms have become makeshift hospitals.

People were missing their limbs, people had open abdomens and exposed intestines, brain injuries with exposed brain matter. And these were civilians. I saw children and adults with testicular injuries because they were shot in the genital area. It seemed civilians were being targeted with an aim to mutilate and maim.

When air strikes would occur or there would be a round of mortar shelling, you'd always know if people got hurt because you'd hear screaming. The hospital was close to the front lines, and people would pile up at the door, sometimes you'd have to put people on the floor. They'd show up covered in dust, covered in blood. It was Ramadan at the time, and one night there was a market where people donated clothes for the poor, and that market got hit by a missile. They were just families looking for clothes, and they found themselves in the hospital with horrible injuries.

Another night there was an air strike and a boy was found unresponsive with no pulse in the street, brought in by strangers to the hospital. He had a hole the size of football in his thigh and bone fragments falling out of his wound and a fractured femur with a severed femoral artery. There was blood spattered from the street to his stretcher.

He was brought into the emergency room, and all the doctors, nurses and medical students played their roles, like clockwork. One was doing CPR, others were putting in IVs. Someone pinched his femoral artery closed. When we got a pulse back, we took him down to the OR, clamped his femoral artery, and placed an external fixator to stabilize his fracture. A vascular surgeon came from another hospital and was able to transplant a superficial vein from the boy's other leg to create a new artery. He survived.

The next day his dad found him at the hospital by asking around in the city. It's the small things, the everyday actions of doctors and nurses working together, that can unite a son with a father."